Gynecomastia: Evaluation and Management with Modified Intra-areolar Incision at Tertiary Care Center

INTRODUCTION

Gynecomastia is the most common benign breast condition in men, caused by proliferation of the ductular element and adipose tissue.¹ Gynecomastia is ranked the 10th most common surgical procedure done by plastic surgeons as per the International Society of Esthetic and Plastic Surgery international survey on esthetic and cosmetic procedures (2010).²

Glandular, fatty glandular, and fatty are the major types of gynecomastia.^3,4 The glandular and fatty glandular types are commonly seen in puberty.⁵ Fibrosis, and hyalinization of loose periductal tissue occurs in chronic gynecomastia patients that lead to hypertrophy of glandular component.⁶

Semi-circular intra-areolar incision was described by Duoformental and documented by Webster,⁷ they emphasized on conspicuous scarring due to use of old techniques. The removal of glandular component remains the concern in liposuction, therefore, liposuction was combined with different kinds of incision to excise the fibrous tissue in make breasts.^8,9 Easy excision of fibro glandular tissues without scarring is emphasized in this article by use of modified intra-areolar incision. Excision of this periareolar glandular tissue is of extreme importance in such cases. The main aim is to differentiate gynecomastia from fatty breasts (lipomastia or pseudogynecomastia), breast cancer, and to know the cause of the gynecomastia.¹⁰ The results are evident on the operative table with minimal to no disruption of areola and nipple and minimal scarring.

MATERIALS AND METHODS

Male patients presenting to OPD between September 2021 and September 2022 were included in the study. Patients with Simon’s grade I–III were included in the study. Patients were evaluated in Medical Endocrinology Department before surgical excision for evaluation of cause of gynecomastia. All patients underwent either liposuction alone or combined with gland excision with modified intra-areolar incision.

The surgery was done under general anesthesia. Lesion was infused with tumescent solution, through a stab incision in anterior axillary line. After tumescent liposuction residual glandular tissue under the NAC was palpated. Glandular tissue was removed using a modified intra-areolar incision. A 15-number blade was used to make the incision starting from 3 o’clock of areola then turning around the base of nipple and extending up to 9 o’clock position. An amount of 4–5 mm tissue beneath the areolar skin was preserved to prevent any vascular complications and contour deformities to nipple areola complex (Fig. 1).

After ensuring hemostasis skin was closed with subcuticular 5–0 absorbable suture. The liposuction port suture was also closed with subcuticular 5–0 absorbable suture. Pressure bandaging was applied immediately on OT table. Patient was discharged on POD -1 after dressing change. Oral antibiotics were given for a week. Patient was followed up at 2-weeks, 1-month, and 6-months intervals. Patients were advised use of pressure garment for 6 weeks to 3 months postoperatively.

RESULTS

A total of 13 male patients were included in the study. Patients were graded based on the Simon’s grading of gynecomastia. There were four patients of grade I, seven patients of grade IIa, one patient of grade IIb, and one patient was graded as I on left side and IIa on right side (Table 1). All patients presented with bilateral disease. Liposuction alone was done in two patients and liposuction combined with glandular tissue excision with modified intra-areolar incision was done in rest.

No major complications were seen in the postoperative period. Majority of the patients complained of pain and edema in the immediate postoperative period which responded to analgesics and conservative measures. Improvement in chest contour was seen in all patients with no contour deformities at 1 month follow up, nipple shape was assessed for any inversion, dis-coloration or necrosis of skin. Scar assessment was done at 6-months follow up by Vancouver Scar Scale (Figs 2 to 5).

DISCUSSION

In a male patient with lipomastia (also known as pseudogynecomastia or fatty breasts), weight loss should be recommended. If this strategy fails or the patient is bothered by the lipomastia, surgical intervention is a reasonable option. No treatment is necessary in asymptomatic boys with pubertal gynecomastia or in men with long standing asymptomatic gynecomastia.^10–12 Complete clinical and laboratory evaluation of every patient of gynecomastia is necessary to rule out the reversible causes of the disease. Following the withdrawal of removal of offending agent, the improvement in gynecomastia is observed in few weeks and residual tissue is considered for surgical removal.

Patients of gynecomastia presents to the OPD mainly for esthetic reasons with disease affecting his mental well-being. However, postsurgical scar is also a major concern in such patients. Poor scarring may actually aggravate their mental health issues in-spite of having adequate breast reduction thus defeating the purpose of the surgery. Authors advice liposuction alone^1–15 or liposuction and periareolar incision¹⁶ or pull-through technique.¹⁷ Most patients, that are managed with only liposuction are left behind with a small subareolar elevation due to the left-over glandular tissue that is not removed by liposuction.

A study done by Hammond et al. reported a decrease in sensations of nipple post liposuction and periareolar incision, no such loss of sensation of NAC was reported in our series.¹⁶ Study done by Lista et al. reported using dual incisions for removal of large masses of glandular tissue post liposuction, this study reported removal of such large mass (largest 200 gm) of glandular tissue removed through single scarless incision.¹⁷ All patients followed up at 6 months interval reported no loss of NAC sensation and excellent esthetic results.

The literature states various technique for the removal of this subareolar glandular tissue, but all leave behind some extent of visible scar or affect vascularity of overlying skin or affect nipple sensation. We present a modified intra-areolar incision starting from 3 o’clock of areola then turning around the base of nipple and extending up to 9 o’clock position. About 4–5 mm tissue below, the areolar skin was preserved to maintain the blood supply and prevent any contour deformities. Complete healing was seen in 1 week with no visible scar at 6 months follow up.

This simple technique is effective in removal of fibrous glandular breast tissue. The wound healing occurs without visible scars in the NAC complex. The scars of liposuction canula site were also inconspicuous. Several other studies have reported the use of arthroscopic lasers for the excision of the fibrous glandular breast tissue,^18–20 but all studies had demerits of additional and visible scars.

Patients who present with Simon’s grade IIb and III generally have skin excess along with the glandular and fatty tissue excess. Such patients also require skin reduction along with the conventional treatment done for Simon’s grade I and IIa patients. In the 1970s, Letterman described Dufourmentel-Mouly procedure that was a combination of elliptical incision with bipedicle dermal areolar flap.²¹ Huang et al. in his study has shown that patients who underwent circumareolar excision can be taken up for skin excision with no scarring.²² Patients with severe gynecomastia are treated with skin excision through an infra mammary fold incision with free nipple graft.

CONCLUSION

Study shows successful treatment of gynecomastia with complete removal of both glandular and fibrofatty tissue through power assisted liposuction and modified intra-areolar incision with best esthetic results of no visible scarring with no complications.

ACKNOWLEDGMENTS

The author thanks Dr Ankur Bhatnagar and Dr Anupama Singh for their valuable support.

ORCID

Sabaretnam Mayilvaganan https://orcid.org/0000-0002-2621-394X

REFERENCES

1. Mathes SJ, Seyfer AE, Miranda EP. Congenital anomalies of the chest wall. In: Mathes SJ (ed) Plastic surgery, 2nd edition. Philadelphia: Saunders Elsevier 2006; pp. 457–537.

2. International Society of Aesthetic and Plastic Surgery international survey on aesthetic and cosmetic procedures performed in 2010 (2010). Available from: https://www.isaps.org/media/zu4dtawc/isaps-results-procedures-2010-1.pdf.

3. Morselli PG. ‘‘Pull-through’’: A new technique for breast reduction in gynecomastia. Plast Recontr Surg 1996;97(2):450–454. DOI: 10.1097/00006534-199602000-00028.

4. Bracaglia R, Fortunato R, Gentileschi S, et al. Our experience with the so-called pull-through technique combined with liposuction for management of gynecomastia. Ann Plast Surg 2004;53(1):22–26. DOI: 10.1097/01.sap.0000106429.37110.cf.

5. Nydick M, Bustos J, Dale JH, et al. Gynecomastia in adolescent boys. JAMA 1961;178(5):449–454. DOI: 10.1001/jama.1961.03040440001001.

6. Karsner HT. Gynecomastia. Am J Pathol 1946;22:235–315.

7. Webster JP. Mastectomy for gynecomastia through a semi-circular intra-areolar incision. Ann Surg 1946;124(3):557–575. PMID: 17858862.

8. Barsky AJ, Kahn S, Simon BE. Principles and Practice of Plastic Surgery. 2nd Edition. New York: McGraw-Hill; 1964. p. 566.

9. Letterman G, Schurter M. The surgical correction of gynecomastia. Am Surg 1969;35(2):322–325. PMID: 5782230.

10. Narula HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin North Am 2007;36(2):497–519. DOI: 10.1016/j.ecl.2007.03.013.

11. Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab 2011;96(1):15–21. DOI: 10.1210/jcem.96.9.zeg15a.

12. Ikard RW, Vavra D, Forbes RC, et al. Management of senescent gynecomastia in the Veterans Health Administration. Breast J 2011;17(2):160–166. DOI: https://doi.org/10.1111/j.1524-4741.2010.01050.x.

13. Rosenberg GJ. A new cannula for suction removal of parenchymal tissue of gynecomastia. Plastic Reconstr Surg 1994;94(3):548–551. DOI: 10.1097/00006534-199409000-00023.

14. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and Management of gynecomastia: Defining the role of ultrasound assisted liposuction. Plast Reconstr Surg 2003; 111(2):909–925.DOI: 10.1097/01.PRS.0000042146.40379.25.

15. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg 2005;116(2):646–655. DOI: 10.1097/01.prs.0000173441.57812.e8.

16. Hammond DC, Arnold JF, Simon AM, et al. Combined use of ultrasonic liposuction with the pull through technique for the treatment of gynecomastia. Plast Reconstr Surg 2003;112(3):891–895. DOI: 10.1097/01.PRS.0000072254.75067.F7.

17. Lista F, Ahmad J. Power assisted liposuction and pull through technique for the treatment of gynecomastia. Plast Reconstr Surg 2008;121(3):740–747. DOI: 10.1097/01.prs.0000299907.04502.2f.

18. Benito-Ruiz J, Raigosa M, Manzano M, et al. Assessment of a suction-assisted cartilage shaver plus liposuction for the treatment of gynecomastia. Aesthet Surg J 2009;29(4):302–309. DOI: 10.1016/j.asj.2009.02.020.

19. Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver. Plast Recontr Surg 2005;115(3):939–942. DOI: 10.1097/01.prs.0000153237.35202.7d.

20. Song JY, Han BK, Kim CH. The treatment of gynecomastia using XPS microresector (shaver). J Korean Soc Plast Reconstr Surg 2009;36:806–810.

21. Letterman G, Schurter M. Surgical correction of massive gynecomastia. Plast Reconstr Surg 1972;49(3):259–262. DOI: 10.1097/00006534-197203000-00003.

22. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in surgical management of gynecomastia. Plast Reconstr Surg 1982;69(1):35–40. PMID: 7053509.